OIG asks CMS to help improve reporting of abuse, neglect in nursing homes

Caregiver end of life care nursing home palliative care
The Department of Health and Human Services is asking the Centers for Medicare & Medicaid Services to do a better job of reporting abuse at nursing homes. (Getty/KatarzynaBialasiewicz)

The Department of Health and Human Services Office of Inspector General (OIG) recently released two documents that address the lack of reporting when it comes to incidents of abuse and neglect of Medicare beneficiaries in skilled nursing facilities (SNFs).

The first report examined why incidents of possible abuse or neglect at SNFs were not always reported or investigated as required by federal law.

Looking at available data, the OIG estimated that 1 in 5 high-risk hospital ER Medicare claims in 2016 was the result of potential abuse or neglect of someone residing in a SNF. However, SNFs failed to report many of these incidents in accordance with federal requirements, and some associated service agencies failed to report findings to local law enforcement, OIG found.

RELATED: OIG: CMS improperly paid $84M to nursing facilities that failed to follow its 3-day rule

The report concluded that lack of reporting goes back to the Centers for Medicare & Medicaid (CMS), which does not require all incidents of abuse or neglect be reported to law enforcement.


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The report recommends that CMS take action to ensure that all incidents of potential abuse or neglect of Medicare beneficiaries in SNFs are identified and reported with the survey agencies. This includes improving staff training to identify neglect.

The recommendations were based on a review of 37,607 high-risk hospital ER claims for 34,820 Medicare beneficiaries residing in SNFs during the 2016 calendar year.

More specifically, of the incidents of potential abuse or neglect, 2,574 were allegedly perpetrated by a healthcare worker, 3,330 were related to incidents that occurred in a medical facility and 9,294 were related to incidents that were not reported to law enforcement.

RELATED: CMS plans to release list of 400 troubled nursing homes

But CMS did not identify similar incidents during the period of review because, according to CMS officials, it did not extract data consisting of Medicare claims containing the 17 diagnosis codes related to abuse or neglect.

Therefore, moving forward, the OIG recommends that CMS compile a list of diagnosis codes that indicate potential abuse or neglect, use that list to conduct periodic data extracts of all Medicare claims containing at least one of those codes, inform states that the extracted Medicare claim data are available to help with mandatory reporting laws and assess the sufficiency of existing federal requirements.

According to the OIG, CMS agreed to the fourth request for assessing existing requirements, but not to the first three recommendations.

“We respectfully disagree with CMS and continue to recommend the use of the Medicare claims data to identify and address potential abuse and neglect of beneficiaries,” the OIG said in a statement.